In search of wellness

Jacqueline Swank, an assistant professor of counselor education and researcher at the University of Florida, believes in the power of nature. “I grew up on a farm,” she says. “Every aspect of my life involved nature.”

The barnyard and surrounding woods were her playground, but living close to nature offered her more than amusement. “Nature was also a place I turned to in order to cope with things,” says Swank, a member of the American Counseling Association. Those experiences have informed her career in both research and practice, where she studies the effects of nature on child and adolescent wellness.

Wellness is something of a buzzword these days, touted and tossed about in pop culture and by various professions. But in counseling, wellness is much more than the latest passing fad — it is entwined in the roots of the profession.

“Counseling has embraced wellness from the beginning,” says ACA Chief Professional Officer David Kaplan. “Expanding on the profession’s initial focus on vocation, we have embraced a comprehensive, holistic approach to wellness that includes not only work, but also a sense of self-worth, spirituality, emotional awareness, coping skills and problem-solving, an emphasis on relationships and other elements that are essential to living a balanced life.”

“Helping clients become as healthy as possible is, and always has been, a central tenet of professional counseling,” he adds.

So much so that when delegates to the 20/20: A Vision for the Future of Counseling initiative developed and agreed on a unified definition of counseling in 2010, wellness was one of the components explicitly highlighted: Counseling is a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals.

But given that wellness is a core component of the definition of counseling, how does the profession define wellness itself?

Jane Myers, along with frequent co-author and spouse, Thomas Sweeney, has studied wellness for years. Their research led them to develop the Wheel of Wellness, a complex model of individual and societal factors that influence well-being, and later the Indivisible Self, an evidence-based model of wellness that is grouped according to the five factors of the self: the Creative Self, the Coping Self, the Social Self, the Essential Self and the Physical Self.

“The essence of wellness is the integration of mind, body and spirit. It is not static but constantly changing day to day,” says Myers, a past president of ACA and executive director of Chi Sigma Iota, an international honor society that values academic and professional excellence in counseling.

Although counseling has always been committed to helping each client become as “whole” a person as possible, for much of the profession’s history, counselors didn’t feel it was appropriate to ask clients about their spirituality or to become involved with physical health issues, Myers notes.

“I think we’ve moved to a very holistic view as a profession, understanding that all parts of the human experience are related, and we can’t leave anything out if we are going to be effective for our clients,” Myers says. “Everything affects everything else.”

“Emotions are so physically and biologically based in the body that, as counselors, we can’t afford not to look at the whole person,” she adds.

Myers thinks counselors across the profession have become more aware of the importance of wellness in practice, thanks in part to ongoing professional development and to graduate counseling programs’ current focus on wellness in their curricula. The profession is also realizing that this holistic model of wellness is a crucial part of what sets counseling apart from other mental health disciplines, she says.

Sweeney, executive director emeritus of Chi Sigma Iota and also a past president of ACA, sees wellness as an extension of counseling’s original roots in guidance and thinks the profession needs to reclaim this territory.

“Counselors are agents of change — there to help people step by step,” says Sweeney, who is also professor emeritus of counselor education at the Ohio University College of Education.

Myers and Sweeney also believe that tools such as biofeedback and neurobiofeedback and areas of research such as neuroscience and cardioneurology will continue to expand the profession’s understanding of wellness in years to come.

The power of nature

Swank sees nature as a vital component of wellness. As a practitioner, she worked primarily with troubled children and adolescents, including two years at a therapeutic wilderness program for troubled boys. The camp offered many outdoor activities, but one project that grew to be particularly successful had humble roots. “I started a garden with just a few boys who were interested in it,” Swank says, “but as plants started to grow, others developed an interest.”

The little garden blossomed into a kind of life skills school. Swank watched as the boys began developing socials skills while working together in the garden. When deer invaded the garden, the boys also had to cultivate problem-solving skills quickly.

The garden became a source of pride. “The boys were proud to show their parents the produce they had grown,” Swank recounts. “They said that this gave them an opportunity to show their parents and others that they could be successful in doing something positive instead of negative, and this made them feel good about themselves.”

Many of the boys in the wilderness program had been in detention facilities. Most of them were from urban environments and had limited experience with nature, Swank says. Unhooked from electronic devices and without many of their normal conveniences at the wilderness school, the boys had to learn new ways to react and cope.

“They learned that they could not only survive but thrive in a natural environment by learning to rely on nature and each other,” Swank says. “Relying on each other and having to learn to live in a group setting also altered the way the boys viewed their own behavior. They began to understand that their behavior affected those around them, and not just themselves.”

Swank also witnessed the calming, comforting effect that nature had on children in another therapeutic environment. “When I worked in day treatment and inpatient, we created a butterfly garden, and the children and adolescents often requested the opportunity to go sit in the garden to relax and calm down,” she says. “They also considered this a safe, comforting environment to talk with the counselor.”

Swank is now involved with wellness research. Last year, she conducted a study involving gardening and elementary school children.

“We found that children’s self-esteem improved following participation in the gardening groups,” she says. “Many of the children struggled academically, and they were able to experience success in the garden.” She adds that the children also said they felt happier in the garden and liked working together.

The program was so successful that the school counselor contacted Swank to talk about continuing the program. The children had been asking the counselor when they could go to the garden again.

Exploring ‘EcoWellness’

Ryan Reese, an instructor of teacher and counselor education at Oregon State University-Cascades, co-developed with Myers the concept of EcoWellness, which explores the power of nature when integrated into the counseling process. He contends that experiencing nature in whatever manner — in a garden, on a mountaintop or even through an image on the computer screen — holds the potential to increase a person’s sense of well-being.

“I think nature is really at the core of who we are and that the connection runs deep,” says Reese, an ACA member who offers individual and family counseling services in natural settings. “In the last several centuries — because of the Industrial Revolution and the age of technology — we’ve really removed ourselves from it. Before that, we were really reliant on nature for survival.”

Although most of us are no longer quite so dependent on nature in our day-to-day lives, Reese believes that the mind and body still need and crave that connection. He notes research showing that even if people are sitting inside, a view of the natural environment — even in a mural or on a computer screen — reduces their heart rate and can reduce symptoms of depression and anxiety.

In fact, a research study described in a 2010 issue of the Journal of Environmental Psychology found in a series of studies that nature has an energizing effect on people. Many of the studies took place outdoors, but one study was conducted inside, with participants viewing photographs of either buildings or natural scenes. Those viewing the nature scenes received the same kind of energizing effects; those viewing the images of buildings did not.

In addition to an evolutionary need for nature, Reese cites the attention restoration theory developed by psychologists Rachel and Stephen Kaplan in the 1980s. The theory posits that activities such as reading, watching television or being on the computer require “hard attention” — a kind of attention that makes the brain work hard and which can leave people feeling tired and grumpy. In contrast, experiencing nature doesn’t require such hard focus or thought, and can thus provide a break for the brain and give people a sense of “being away from it all.”

Reese uses nature as a wellness tool in his private practice with clients who are interested. “I’m pretty careful not to promote my own agenda. All counselors should be aware of this, especially those [who] want to integrate nature,” he says.

Some clients like to have outdoor counseling sessions in which they walk with Reese on local trails while talking about their concerns. “It is often more comfortable for the clients to talk as we are walking,” he says. “For some — especially adolescents and men — it helps remove the stigma attached to sitting down face to face and talking about their emotions.”

One of Reese’s clients insists on all counseling sessions being outside. But for another client, being outdoors made it easier for her to dodge her issues, so Reese moved the sessions back inside.

Sometimes clients mention visiting an outdoor space in the past that gave them a sense of relaxation or freedom. When that happens, Reese requests that they do some homework — namely, revisiting that place and practicing being mindful or just “being.”

In other instances, Reese uses nature as a metaphor with clients because they don’t know how to describe what they are feeling or don’t want to confront it directly. For example, he worked with one young boy who had been acting out in school, including yelling at and hitting his classmates. During their first session together, Reese talked to the boy about nature and being outside. He discovered the boy liked to go to a local park and would be excited about meeting Reese there. With the mother’s permission, they met at the park and eased into the therapeutic environment by walking and throwing a ball. One day, Reese asked the boy to show him something in nature that he felt best described him.

“He pointed to this shriveled up, leafless, dying tree that was isolated, with no other plants around,” Reese recalls. The boy identified with the tree because it didn’t have any “friends” around it.

Reese then asked the boy to point to something that represented what he wanted to be. The boy pointed to a big, tall tree surrounded by many plants. In the boy’s eyes, this meant the tree had many friends and “shared” its shade with others.

The two trees gave Reese the opening he needed to assess the boy’s problems and goals. Going back to the trees helped the boy talk about his difficulties — and his progress — in a nonthreatening way, and his behavior gradually began to improve.

Reese thinks the natural environment is the missing piece in wellness models. In fact, the EcoWellness concept he co-developed (first described in the October 2012 issue of ACA’s Journal of Counseling & Development) posits that a person’s wellness is affected by the extent to which he or she is connected with nature. Reese has gone on to create the EcoWellness Inventory, which is a way of measuring the effect of nature on an individual’s overall wellness. Currently under peer review, the inventory is based on seven major factors: physical access to nature, sensory access, connection, protection, preservation, spirituality and community connectedness.

Discovering the sacred

For some people, a connection to nature may be sacred. Others may find what they are seeking in a church, a temple or a mosque. Still others may reach a higher plane through meditation. Spirituality can come from organized religion or from a quiet place within oneself, but wherever one finds it, it can be an important part of wellness, says Craig Cashwell, a professor in the University of North Carolina at Greensboro Department of Counseling and Educational Development.

Participating in religious communities or spiritual practices can enhance wellness by cultivating a sense of peace and hope, which Cashwell considers antidotes to depression and anxiety. That’s why he believes that counselors should not be afraid to incorporate spirituality into the counseling process when appropriate.

“I think a lot of counselors really struggle with that because there’s a fear of imposing values on clients. That’s a wise fear to have, but I don’t think it should be a crippling fear that keeps us from exploring these issues with clients and making informed decisions about how and where and if to integrate spirituality into our counseling,” says Cashwell, who is also a private practitioner and the co-author of Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice, published by ACA.

“We start by distinguishing between religion and spirituality. For many people, those two are very tightly connected, but they’re not the same things,” Cashwell says. “Spirituality is a very personal set of beliefs and practices that are used to cultivate a spiritual life. For some people, this calls for a connection to a higher power, while for others, it’s more a kind of connection with their higher selves. I like to think of it as a personal process of transcending our own ego and sort of connecting to something bigger than ourselves.”

As for how to integrate spirituality into counseling, Cashwell says that depends on whether it is appropriate to the process and whether the client is open to it. “It can take lots of different forms,” he says. “[For example], we often use bibliotherapy in lots of different ways, encouraging clients to read particular books. In some cases we do consultations and referrals with members of the religious community when it’s beyond our scope as counselors, encouraging [clients] to talk to an imam, rabbi, priest or pastor, or whatever term they use, about particular issues when it’s appropriate.”

Counselors can also encourage clients to participate in spiritual activities if those activities tie into the clients’ belief systems, he adds.

But Cashwell cautions that spirituality is not always beneficial to wellness. “I think spirituality and religion can both be very vital aspects of wellness for people, but they can also be processes though which people are less well. It really depends upon how healthy the religion or the spirituality is,” he explains. “There are lots of examples of very toxic beliefs and practices out there that can actually decrease wellness.”

“When someone sort of self-identifies with a religious label or a spiritual label, as a counselor that tells me virtually nothing at all about that person,” he says. To determine whether a client’s spirituality is enhancing his or her wellness, the counselor needs to move beyond labels and ask about the person’s practices and beliefs, he emphasizes.

As an example, Cashwell recounts one client’s case, leaving out many of the details to protect the person’s privacy.

“I had a client who was recovering from an addiction. Two of the many questions on my intake form involve spirituality: ‘How important is spirituality or religion to you?’” — measured on a five-point scale — “and the follow-up question, ‘Is this something you would be interested in talking about in counseling?’ On this client’s intake form, he circled a very high number for spiritual importance, but when responding to the question about talking about it, he circled ‘No,’ which is always an interesting combination.”

When Cashwell gets that kind of response, he respects the client’s wishes. But as Cashwell and the client developed a stronger relationship through the first few sessions, he returned to the topic to ensure he had understood the client properly.

“What it came down to was he had a long history of being very religious, and it had created a lot of shame for him around his addiction,” Cashwell explains. “I asked him if he engaged in any spiritual practices, and he said, ‘Well, I used to pray all the time. I used to pray every day, multiple times throughout the day, and always at the beginning of the day.’ Obviously this was an important spiritual practice for him, so I asked, ‘Used to?’ And he quoted Scripture for me from the Book of Psalms, which is part of the Christian Bible, and this text basically said that God doesn’t hear the prayers of the unjust.”

In addition to being in recovery from addiction, Cashwell’s client had been medicated for obsessive-compulsive disorder. “He basically began to ruminate on that particular piece of Scripture and this belief that he was beyond forgiveness, beyond redemption and beyond mercy,” Cashwell says. “Psychologically, that was obviously not a good place for him, because he was basically saying, ‘I’ve done so many bad things, I’m such a horrible person, that I’m lost to any higher power in the universe. They don’t care about me.’”

“This was an attachment issue — a connection issue with his higher power,” Cashwell continues. “I knew better than to go at that directly because that could just create resistance on his part. But we began to talk about that, and I began to ask more about it, and I ended up asking for written permission to talk to his pastor. The pastor was astonished and said that this was not what the religion teaches us.”

The pastor met with the client and assured him there was nothing he had done that could not be undone or forgiven. Cashwell says that trying to advise the client of that himself would have blurred his role as a counselor. Reaching out and inviting in someone who was a significant spiritual influence in the client’s life was more effective,
he notes.

“He still struggled with it, but it really was an epiphany for him,” Cashwell says. “He began to entertain the notion that maybe — in his language — he could be redeemed, he could be forgiven for what he had done and that God did still care for him.”

“That’s an example of how, as counselors, we have to be careful of how we work with spirituality,” Cashwell says, “but it’s also an example of a time when it was powerfully evident that spirituality needed to be part of the treatment. I wasn’t the spiritual expert — his pastor was — but he could go talk to him and come back and discuss things with me. I didn’t blur the roles there. I could just use my counseling skills to help talk him through the process. If we hadn’t touched on that, hadn’t worked with that, I’m not sure he would have been able to stay sober because that was just a deeply rooted sense of shame for him.”

Whether they attach spirituality to it or not, Cashwell thinks most clients could benefit from engaging in some sort of contemplative practice.

“The beauty of that is it can take lots of different forms,” he says. “If the client is a practicing Buddhist or open to other spiritual traditions, you can talk about it as mindfulness, but for other clients who are indifferent to or opposed to religion, you can use Jon Kabat-Zinn’s work, which gives a more psychological and scientific slant to it. Of course, the largest religious group in the country is Christian, and within Christianity there are also some contemplative practices such as centering prayer and contemplative prayer.”

Cashwell points out that a small percentage of clients, such as those with schizophrenia or those with obsessive-compulsive disorder who ruminate, will not benefit from contemplative practice. But it can provide a wellness boost for most other clients. “It’s up to us to figure out what form that might take given the client’s spiritual views,” he says.

Art as an avenue to wellness

Andrea Berry believes art offers a therapeutic way to express difficult emotions. She also views art as a kind of creative mindfulness practice that can enhance wellness by helping people to feel grounded, calmer and more “centered.”

Berry is a private practice counselor and certified art therapist in Laramie, Wyo., who specializes in art therapy and counseling clients with medical conditions. Some of her clients come for her wellness program, which she describes as part counseling/part coaching.

Her practice is informed by her past as a clay potter. The clay wheel is used for centering the potter’s work, and it stands as Berry’s metaphor for wellness. “When you work with clay, you learn about centering the clay on the wheel, which actually makes it stronger and more flexible. You can make it bend and stretch without cracking,” explains Berry, a member of ACA. “You can build pressure [when manipulating the clay], move through the pressure and go through the fire and remain strong. The potter opens up the clay and stretches it — that is the job of the counselor — guiding, allowing the clay to remain strong.”

The art projects Berry uses vary from client to client. She says she doesn’t follow a “process” when choosing art projects; rather, it is intuitive and collaborative. “I might do some mandala work or some altar building. Or, I might teach people knitting or crocheting,” she says.

“I am also into gratitude and giving,” she continues, “so we talk about how wellness doesn’t have to be about you.” Her clients sometimes make things for other people, and Berry asserts this action often ends up boosting the clients’ mood and wellness.

Berry also takes a holistic approach, paying attention not just to mind and soul, but to body as well. “I refer people to nutritionists, physiologists, trainers … I even have clients who go to the gym with me,” she says. “I become the guide and share in their triumphs and struggles. I talk about my journey, and we work together to maintain wellness.”

Berry also uses art with clients who are trying to return to a state of wellness. “I work using a lot of nonverbal expressive therapies with people who are dealing with medical conditions themselves, people who have caregiver issues or [people] coping with bereavement,” she says. “There is a lot of evidence-based research in psycho-oncology on the use of expressive modalities — particularly art — for posttraumatic work.”

In fact, a 2006 study published in the Journal of Pain and Symptom Management found that art therapy helped reduce many cancer symptoms.

The medical process is traumatizing both physically and emotionally, and it can be hard for people to express that trauma verbally, Berry says. “It isn’t prefrontal cortex stuff — it’s gut stuff, it’s heart stuff,” she says. “So art therapy is a good nonverbal way for people to connect the head and the heart.”

Berry believes it is not only easier but also more effective to express trauma nonverbally. “We can talk our way through something, but we are not actually changing our internal response,” she says.

Berry says she creates a safe space for people to express themselves through art. “It’s about empowering the client — the client is the artist,” she says. Berry then helps her clients process the experience by talking about what they have produced.

“The specific projects vary from client to client,” she says. “For instance, I worked with a woman with dementia, and we made ‘scribble drawings’ together. We just sat there and scribbled. Part of her treatment plan was to have her engage with another person and have as much interaction as possible.”

At its most basic, the process involved Berry and the woman picking colors, scribbling and watching to see what emerged. “One day we came up with clouds and made a story,” Berry says. “This pushed her to go back and forth in conversation.” That experience represented genuinely hard work for the woman, Berry says, but strengthening that aspect of her functioning was a crucial part of her treatment plan.

In another case, Berry worked with the family of a teenager who had cancer. “We did collage work, and they all made collages of their experience of how cancer had changed their family — both good and bad — and then we talked about that.”

Helping the mind by helping the body

Kathleen Douthit, associate professor and chair of the counseling and human development program at the University of Rochester’s Warner School of Education, believes adopting a wellness perspective requires acknowledging the literal link between mind and body. She studies psychoimmunology (PNI), a discipline that explores how the mental process is linked to the nervous, endocrine and immune systems. By peering through the lens of PNI, she says, one can see a clear path from what we consider to be “just thoughts” to actual physical manifestation.

A crucial part of wellness is a healthy connection and collaboration between mind and body, says Douthit, a member of ACA. When stress becomes chronic, the mind and body “collide” rather than “connect.” This starts a chain reaction in the body that damages the nervous, endocrine and immune systems, she explains.

A healthy immune system is in constant communication with the nervous and endocrine systems. But chronic stress causes an information overload that derails this communication and causes immune system chaos, she says. A damaged immune system can’t perform all the functions that help keep us well. Inflammation then starts and damages multiple mind and body systems, Douthit explains.

“Inflammatory disease can cause conditions such as cardiovascular disease, fibromyalgia and chronic fatigue. Inflammation can also cause dementia later in life,” she says. “Once you start getting into something like cardiovascular disease, then you have inevitable problems with depression. If you don’t have enough blood getting to brain cells, you start running the risk of psychological problems.”

In addition to the effect of reduced blood flow, there are more direct assaults on mental health. For example, inflammation causes problems with neurotransmitters, Douthit says.

“There is some thought that this alteration is the key to some serious psychological disorders,” she says. “So, not only do you get a breakdown of the neurotransmitter process, you also have all these inflammatory cells floating around. You end up getting suppression of neuroplasticity, and that becomes really key in being able to lay down some of the pathways that we try to lay down in counseling.”

The good news, Douthit says, is that counselors are in a prime position to help by assisting clients in establishing a wellness regimen that combats stress and interrupts or mitigates this sinister chain reaction. Counselors can also help clients find support and assistance with areas such as nutrition and fitness, she says.

“There are all sorts of reasons that people aren’t willing to face their lack of wellness,” Douthit says. “Counselors can be really key to helping people work through that resistance — and that’s lifesaving. If you can really get someone to understand highly self-destructive patterns, you can help them understand the importance of intervening on their own behalf.

“Acknowledging the mind-body process — to me that is the key to human development,” concludes Douthit.

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